Brand Name Drug: A medication sold by a pharmaceutical company under a trademark-protected name. Brand name medications can only be produced and sold by the company that holds the patent for the drug.

Cash and Carry: A provision of Deductible 3 Plus is that you pay the full cost of the prescription and are reimbursed for 80% of Wellmark’s allowed amount after you meet your deductible. If you use a participating pharmacist, the pharmacist files the claim for you. If you do not go to a participating pharmacy, you will have to submit a paper claim to Wellmark and be reimbursed at 80% after the deductible of what Wellmark would have paid to a participating pharmacy.

Copayment (Copay). Your share of the cost of a prescription. You pay a specified amount of out-of-pocket expenses with Wellmark paying the remaining cost. For example, except for the Deductible 3 Plus plan, there is a $5 copay for a 30-day supply of a preferred generic drug.

Coinsurance. The percentage of the covered costs that is your responsibility after the deductible has been paid. The Deductible 3 Plus plan requires you to pay 20% of the cost of a prescription after meeting the deductible.

Deductible. The amount you pay each year toward your initial covered expenses before the plan begins to pay benefits. For example, the Gold Preferred plan (only available to retirees) has a $100 deductible except for generic drugs.

Drug Formulary: A list of prescription drugs, both generic and brand name, that helps guide physicians and pharmacists in selecting the medications that provide the most appropriate treatment for the best price.

Generic Drug: A copy that is the same as a brand-name drug in dosage, safety, strength, how it is taken, quality, performance and intended use.

Maintenance Drug. A medication that is generally used to control a condition or disease that lasts for an extended period of time (up to a lifetime). These medications do not cure a condition or disease but do control it. A few examples of these conditions and diseases include diabetes, high blood pressure (hypertension), cholesterol, and asthma.

Non-Maintenance Drug. A medication used to treat short-term conditions. These medications will cure or help to cure a disease or condition. These medications are taken for a short period of time and when the disease or condition is cured there is no need to continue taking the medication. A few examples of these conditions and diseases include bronchitis, ear infections, sinus infections, bone or muscle injuries.

Out-of-Pocket Limit. The most you would ever have to pay for prescription drugs in a year. The Iowa Select and Program 3 Plus plans have a out-of-pocket limit just for prescription drugs. Once you reach the out-of-pocket limit, you will not pay for any prescription drugs copays for the rest of the year.

Specialty Drug. A medication that is high-cost, injectable, infused, oral or inhaled drug for the ongoing treatment of a chronic condition. These medications generally require close supervision and monitoring of the patient’s drug therapy.

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Side-by-Side Comparison of the Prescription Drug Benefits

A side-by-side comparison of the prescription drug benefits of the different health insurance plans is available for your review.

Prescription Drug Benefit Comparison (active employees)
Prescription Drug Benefit Comparison (retirees before Medicare-eligibilty)

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Drug Formulary

As mentioned above, a drug formulary is a list of prescription drugs, both generic and brand name, that helps guide physicians and pharmacists in selecting the medications that provide the most appropriate treatment for the best price.

Wellmark's Drug Formulary

Wellmark reviews and updates the formulary regularly to ensure that it continues to provide coverage for drugs that are cost effective and safe. Drugs on the formulary are grouped into three tires and your copayment is determined by the tier your medication is on.

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Participating Pharmacies

Wellmark contracts with Catalyst Rx to manage its pharmacy network. Catalyst Rx contracts with thousands of major chains and independent pharmacies throughout the country. Catalyst Rx adds pharmacies to its network on a regular basis.

Show your Wellmark ID card when you fill a prescription at a participating pharmacy to save time and money. Network pharmacists have computer access to current member information to help them identify duplicate therapies or interactions from drugs dispensed by other network pharmacies.

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Mail Order Prescription

All of the State of Iowa's health insurance plans offer a mail order prescription drug benefit except Deductible 3 Plus.

The mail order drug benefit allows you to order prescriptions drugs through the mail. You can receive a 90-day supply for just the cost of two copays instead of the three copays that you would receive by ordering the prescription from a retail site.

The advantages of ordering prescription drugs through the mail are:

Saving the cost of a copay
Convenience of the prescription drug mailed to your home

Example:

In this example, you are enrolled in Blue Access, family coverage. You or someone in your family takes a maintenance medication. The copay for the prescription is $15 for a 30-day supply. If you refill that prescription at a retail pharmacy every month, you will spend $180 per year on that prescription ($15 copay x 12 months.)

Instead of refilling that prescription drug every month at a retail pharmacy, you decide to utilize mail order. For a 90-day supply, your copay will only be $30. That’s just two copays of $15. Because you get a 90-day supply, you will only refill the prescription approximately 4 times a year. Using mail order, you will only pay $120 per year ($30 copays x 4 times a year.) That’s a savings of $60 per year for just one prescription!

Think what your savings could be if you or your family member has more than one maintenance medication or the copay was $30 per prescription.

There is no charge for standard shipping of your prescription orders. If requested, expedited shipping is available. Standard order are shipped via U.S. Postal Service .However, UPS is used for secure next day delivery when an order contains a time sensitive, temperature-sensitive item, or an extremely high-cost item.

If you want to start using mail order prescription services:

Ask your doctor to write out 2 prescriptions:

One for a short-term supply (e.g., 30 days) that you can fill immediately at a participating retail pharmacy
The second for up to a 90-day supply of maintenance medications, plus refills.

Use one of the following methods to start your mail order prescription.

Complete the Registration and Prescription Order Form and mail with your prescription. You can also register by calling Wellmark’s mail order pharmacy customer service toll-free at 1-866-611-5961. Mail service representatives are available Monday through Friday, from 7 a.m. - 9 p.m. CT or Saturday, 7 a.m. - 4 p.m. CT.
OR
Fill out your information on the Prescription Fax Order section and ask your doctor to complete and fax the form.

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Generic Drugs

The next time you need a prescription filled, ask your doctor or pharmacist if it is available as a generic. You can save on your out-of-pocket costs by choosing generic medications when available and appropriate.

Following are some answers to commonly asked questions about generic drugs.

What are generic drugs?

A generic drug is a copy that is the same as a brand-name drug in dosage, safety, strength, how it is taken, quality, performance and intended use.

Are generic drugs as safe as brand-name drugs?
Yes. The Food and Drug Administration (FDA) regulates and monitors the quality of all drugs, both brand name and generic. The generic manufacturer must provide evidence that the drug has the same active ingredients and works the same way in the body as the original brand-name product.

Why are generic drugs less expensive?

I hear the terms generic equivalent and generic alternative or therapeutic alternative. What is the difference between these?

Are all drugs available as a generic?

No. Many are still protected by patent and are sold as brand-name only. However, more than half of all brand-name drugs do have generics available. Your doctor or pharmacist can tell you if your prescription is available as a generic and if it’s the right choice for you.

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3 Ways to Save on Prescription Drugs

You can save time and money by doing these three things:

Always choose a network pharmacy.
Show your Wellmark identification card to your pharmacist when you get a prescription filled. Your network pharmacist will submit your bill for you.
Choose generics whenever possible. Ask your physician whether the drug he or she is prescribing for you is generic. If it isn't, ask whether a generic equivalent drug is available.

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Specialty Prescription Drugs

Specialty drugs are high-cost, injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient’s drug therapy.

Specialty drugs:

Require special handling and administration
Require temperature controlled shipping
Require careful adherence to treatment protocols
Require special monitoring or testing
Are used for chronic illness or rare medical condition
Are high-priced drugs ($1,500 -- $100,000 annually)

Self-administered specialty drugs are covered under the prescription drug provision of your Wellmark health insurance plan (except for Deductible 3 Plus).

There are approximately 70 drugs that Wellmark has identified as self-administered specialty drugs. The Specialty Drug List is available on Wellmark's website. Also, you can contact Wellmark’s customer service about specialty drugs at the phone number on the back of your Wellmark identification card.

Specialty drugs on the list under the “Self Administered” category are only available at the pharmacy as a pharmacy benefit. Drugs on the list under “Self and/or Office Administered” category are available either at the doctor’s office (where they are processed as a health benefit) or at the pharmacy (where they are processed as a drug benefit.) Finally, specialty drugs on the list under the “Office Administered” category are only available at the doctor’s office and are processed as a health benefit.

Depending on the specialty drug, your copy is either Tier 2 or Tier 3. The majority of self-administered specialty drugs are on Tier 3.

The following are the prescription drug copays for the Wellmark plans.

Wellmark Plan	Tier 2	Tier 3
Blue Access	$15 copay	$30 copay*
Blue Advantage	$15 copay	$30 copay*
Iowa Select	$15 copay if you have not reached your maximum out-of-pocket	$30 copay if you have not reached your maximum out-of-pocket
Program 3 Plus	$15 copay if you have not reached your maximum out-of-pocket	$30 copay if you have not reached your maximum out-of-pocket

For Blue Access or Blue Advantage, the cost share for non-preferred brand name self-administered specialty drugs is only the $30 copay. The coinsurance of 25% does not apply to self-administered specialty drugs. The lack of coinsurance only applies to self-administered specialty drugs. It does not affect other drugs on the 3rd tier.

If you receive a self-administered specialty drug from a doctor or other health care provider, the claim under the health plan will be denied and you will be responsible for the cost of the drug. The doctor’s office cannot file a pharmacy claim.

Mail Order

Self-administered specialty drugs cannot be ordered through mail order and the drugs are limited to a 30-day supply.

Preferred Specialty Pharmacy Providers

Specialty pharmacies specialize in the delivery and clinical management of specialty drugs.

Wellmark has two preferred specialty pharmacy providers: Caremark Specialty Pharmacy and Hy-Vee Pharmacy Solutions (HPS). When you use these preferred providers for your specialty drugs, you receive the following services at no extra cost:

Educational materials and ongoing support to help you manage your health
Complete insurance billing, including coordination of benefits for lower out-of-pocket costs and virtually no paperwork
Free courier delivery of medications, often with next-day delivery
Supplies, including syringes, alcohol swabs, and sharps kits, if required
Access to pharmacists and other health experts 24 hours a day, seven days a week
Follow-up care calls to remind you when it is time to refill your prescription, check on your therapy progress, and answer any questions you may have

How to Order Using Caremark Specialty Pharmacy Services
Hours are Monday through Friday, 6:30 a.m. – 8 p.m. CST.

Call CaremarkConnect® at 1-800-237-2767 and identify yourself as a Wellmark Blue Cross and Blue Shield member. A representative will collect your information and contact your physician to obtain a new prescription; OR
Ask your physician to fax a completed enrollment form to 1-800-323-2445. A CaremarkConnect representative will contact you for any information needed to complete the order.

How to Order Using Hy-Vee Pharmacy Solutions
Hours are Monday through Friday, 8 a.m. – 5 p.m. CST.

Call Hy-Vee Pharmacy Solutions (HPS) at 1-877-794-9833 and identify yourself as a Wellmark Blue Cross and Blue Shield member. A representative will enroll you in the program and make arrangements to get your first order delivered; OR
Ask your physician to call in a prescription at 1-877-Rx-HYVEE (1-877-794-9833) or fax a completed enrollment form to 1-402-861-4941. A Hy-Vee Pharmacy Solutions representative will contact you to make arrangements for delivery.

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Vaccines at the Pharmacy

You have the convenience of going to a pharmacy to receive certain vaccines as part of your prescription drug provision of your Wellmark health insurance plan. .

The vaccines that can be administered at the pharmacy and be covered by Wellmark are:

Diphtheria, Tetanus, Pertussis (DT&P)	Measles, Mumps, Rubella (MMR)
Haemophilus influenzae type b (Hib)	Meningococcal (MPSV4)
Hepatitis A (HepA)	Pneumococcal
Hepatitis B (HepB)	Rotavirus (Rota)
Human Papillomavirus (HPV)	Varicella
Inactivated Poliovirus (IPV)	Zoster (over age 60)
Influenza

For some vaccines, you may need a prescription from your doctor. Check with your pharmacy to determine if a prescription is needed.

Not all pharmacies provide vaccines. Only pharmacists, certified to give vaccines, can offer this service. Wellmark has a list of pharmacies that participate in the vaccine program. Also, the hours that vaccines are available may be different than the normal pharmacy operating hours. If your pharmacy is on the list of participating pharmacies, check with your pharmacy regarding the hours the service is available. If your pharmacy is not listed, let them know you are interested in this service.

You can still go to your doctor’s office to receive a vaccine.

Your cost share will be different depending on where you receive the vaccine. Your health benefit will apply if you receive the vaccine in your doctor’s office. If you receive the vaccine at a pharmacy, your cost share will be equal to the preferred brand name drug cost (tier 2).

If you use a pharmacy that belongs to the Wellmark network, your claim will be filed electronically. If you use a pharmacy that does not belong to the Wellmark network, you will have to pay for the entire cost of the vaccine, submit a paper claim and wait for reimbursement.

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SilverScript -- Medicare Part D Prescription Drug Benefit

If you are a retiree, or an employee about to retire and want to know more about Medicare Part D pharmacy benefits, please visit the SilverScript website.

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Additional Pharmacy Information

The DAS Healthy Opportunities Prescription Drugs website contains additional information and resources to assist you in making informed healthcare decisions about prescription drugs.

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Questions

For further information please contact Wellmark's Customer Service number on the back of your Wellmark identification card.

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Last updated 12/20/2012


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